T h e n e w e ng l a n d j o u r na l o f m e dic i n e Images in Clinical Medicine Lindsey R. Baden, M.D., Editor Secondary Palatal Myoclonus A B C A 59-year-old woman with a history of diabetes, hypertension, Sanjeev Sivakumar, M.D. and multiple previous strokes presented for evaluation. Two years earlier, Kumar Rajamani, M.D., D.M. she had an acute onset of imbalance, along with difficulty swallowing and Wayne State University speaking. The neurologic examination revealed dysarthric speech and pseudobul- Detroit, MI bar affect, with a constant, rhythmic jerky movement of the soft palate, which was ssivakum@med.wayne.edu indicative of palatal myoclonus (Panel A, and Video). She reported having no tinnitus or clicking sounds in her ear, which can be associated with this condition. Magnetic resonance imaging of the brain revealed a hypointense lesion in the right A video showing palatal myoclonus lateral pontine tegmentum on axial gradient echo sequence and coronal fluid-at- is available at tenuated inversion recovery (FLAIR) sequence (Panels B and C, arrows), suggestive NEJM.org of hemorrhagic stroke. Secondary palatal myoclonus often occurs as a result of a lesion in the brain stem or cerebellum within the triangle of Guillain and Mollaret and is characterized by contractions of the levator veli palatini muscle. Common causes include stroke, neurodegeneration, infections, demyelination, and trauma. Patients with no apparent structural lesion are considered to have essential palatal myoclonus, characterized by contraction of tensor veli palatini muscles, often resulting in repetitive audible ear clicking or tinnitus. DOI: 10.1056/NEJMicm1412079 Copyright © 2015 Massachusetts Medical Society. n engl j med 373;3 nejm.org July 16, 2015 The New England Journal of Medicine Downloaded from nejm.org at UNIVERSITY OF OTAGO on July 19, 2015. For personal use only. No other uses without permission. Copyright © 2015 Massachusetts Medical Society. All rights reserved. e3